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Sykes PH, Simcock BJ, Innes CR, Harker D, Williman JA, Whitehead M, van der Griend RA, Lawton BA, Hibma M, Fitzgerald P, Dudley NM, Petrich S, Eva L, Bergzoll C, Kathuria J, McPherson G, Tristram A, Faherty J, Hardie D, Robertson A, Robertson V, Pather S, Wrede CD, Gastrell F, Fentiman G, John M, White E, Parker C, Sadler L. Predicting regression of cervical intraepithelial neoplasia grade 2 in women under 25 years. Am J Obstet Gynecol 2022; 226:222.e1-222.e13. [PMID: 34534506 DOI: 10.1016/j.ajog.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/17/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND A number of retrospective and prospective studies have documented substantial rates of regression in cervical intraepithelial neoplasia grade 2 lesions in young women. Initial observational management of cervical intraepithelial neoplasia grade 2 is increasingly accepted as appropriate for women under 25 years of age with screen-detected abnormalities and is included in a number of clinical guidelines. However, there has been a paucity of large prospective studies on observational management with strict inclusion criteria. A number of important questions remain, specifically regarding the clinical variables that are associated with the risk of progression or persistence of disease. To investigate these factors and to ensure that young women with cervical intraepithelial neoplasia grade 2 undergoing observational management were being managed in a well-monitored and an appropriately informed fashion, we conducted a large, multicenter prospective study on observational management of cervical intraepithelial neoplasia grade 2 in women under 25 years. OBJECTIVE This study aimed to determine the regression rates and clinical, cytologic, and pathologic predictors of regression of cervical intraepithelial neoplasia grade 2 in women under 25 years undergoing observational management over 24 months. STUDY DESIGN This study was a multicenter prospective study on observational management of cervical intraepithelial neoplasia grade 2 (ie, repeat colposcopy, cytology, and cervical biopsy every 6 months) for up to 24 months. A total of 615 consenting women under 25 years with newly-diagnosed, biopsy-proven cervical intraepithelial neoplasia grade 2 were recruited (from 2010 to 2016) through 16 hospital-based colposcopy units in New Zealand and Australia. RESULTS At completion, 326 women had confirmed regression, 156 had persistent high-grade cervical intraepithelial neoplasia grade 2 or 3 or adenocarcinoma in situ, and 24 had unconfirmed regression (ie, first regression at the 24-month follow-up). A total of 109 women did not complete the protocol (41 because of delayed follow-up, 41 lost to follow-up, 22 elected treatment, 4 refused a biopsy, and 1 died of an unrelated cause). Confirmed regression was observed in 53% (326 of 615) of all women enrolled in the study and, when missing data were imputed, it was estimated that 64% of women (95% confidence interval, 60%-68%) would have experienced regression. Similarly, lesions regressed in 64% (326 of 506) of women who completed the observational protocol. Based on a multivariable analysis, detection of human papillomavirus 16 in a liquid-based cytology sample at the time of initial colposcopy decreased the chance of regression by 31% (risk ratio, 0.69; 95% confidence interval, 0.56-0.86; P<.001). In addition, at initial colposcopy, low-grade or normal colposcopic impression, later year of diagnosis, low-grade or normal cytology, and being a nonsmoker were all independently associated with an increased chance of regression. CONCLUSION More than half of women under 25 years with cervical intraepithelial neoplasia grade 2 will regress to cervical intraepithelial neoplasia grade 1 or normal within 24 months without destructive treatment. The absence of human papillomavirus 16 is the most important predictor of regression.
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Affiliation(s)
- Peter H Sykes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand; Christchurch Women's Hospital, Canterbury District Health Board, Christchurch, New Zealand.
| | - Bryony J Simcock
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand; Christchurch Women's Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Carrie R Innes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Dianne Harker
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Jonathan A Williman
- Biostatistics and Computational Biology Unit, University of Otago, Christchurch, New Zealand
| | - Martin Whitehead
- Department of Pathology, University of Otago, Christchurch, New Zealand; Canterbury Health Laboratories, Christchurch Hospital, Christchurch, New Zealand
| | | | - Beverley A Lawton
- Centre for Women's Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Merilyn Hibma
- Department of Pathology, University of Otago, Dunedin, New Zealand
| | | | - Narena M Dudley
- Women's Health Service, Waikato District Health Board, Hamilton, New Zealand
| | - Simone Petrich
- Gynaecology Services, Southern District Health Board, Dunedin, New Zealand
| | - Lois Eva
- National Women's Health, Auckland District Health Board, Auckland, New Zealand
| | - Cecile Bergzoll
- National Women's Health, Auckland District Health Board, Auckland, New Zealand
| | - Jyoti Kathuria
- Counties Manukau District Health Board, Auckland, New Zealand
| | | | - Amanda Tristram
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Jim Faherty
- Obstetrics and Gynaecology Services, Southland Hospital, Invercargill, New Zealand
| | - Donna Hardie
- Northland District Health Board, Whangarei, New Zealand
| | - Anne Robertson
- MidCentral District Health Board, Palmerston North, New Zealand
| | | | - Selvan Pather
- Chris O'Brien Lifehouse, Camperdown, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, Australia
| | - C David Wrede
- The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Flora Gastrell
- Nelson Marlborough District Health Board, Nelson, New Zealand
| | - Gary Fentiman
- Nelson Marlborough District Health Board, Nelson, New Zealand
| | - Michael John
- Bay of Plenty District Health Board, Tauranga, New Zealand
| | - Elaine White
- Hawke's Bay District Health Board, Hastings, New Zealand
| | | | - Lynn Sadler
- National Women's Health, Auckland District Health Board, Auckland, New Zealand; Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Righolt CH, Bozat-Emre S, Mahmud SM. Effectiveness of school-based and high-risk human papillomavirus vaccination programs against cervical dysplasia in Manitoba, Canada. Int J Cancer 2019; 145:671-677. [PMID: 30653261 DOI: 10.1002/ijc.32135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/04/2018] [Accepted: 01/08/2019] [Indexed: 11/08/2022]
Abstract
The effectiveness of a vaccination program is influenced by its design and implementation details and by the target population characteristics. Using routinely collected population-based individual-level data, we assessed the effectiveness (against cervical dysplasia) of Manitoba's quadrivalent human papillomavirus (qHPV) routine school-based vaccination program and a short-lived campaign that targeted women at high-risk of developing cervical cancer. Females ≥9 years old who received the qHPV vaccine in Manitoba (Canada) between September 1, 2006, and March 31, 2013 (N = 31,442) were matched on age and area of residence to up to three unvaccinated females. Cox proportional hazards models were used to estimate qHPV VE against high-grade (HSILs) and low-grade squamous intraepithelial lesions (LSILs) and atypical squamous cells of undetermined significance (ASCUS). Among 14-17-year-old participants who had Pap cytology after enrollment, the adjusted qHPV VE estimates were 30% (17-58%) and 36% (21-48%) against the detection of HSILs and LSILs, respectively. There was, however, no evidence of program effectiveness among females vaccinated at ≥18 years of age and among those with a history of abnormal cytology, who were mostly vaccinated as part of the high-risk program. Estimates of VE for females vaccinated in the school-based program are consistent with the expected benefits from qHPV vaccination. No similar benefits were detected among women vaccinated at an older age, and those with abnormal cytology, who were targeted by the high-risk program. Further efforts should be targeted at achieving higher vaccine coverage among preadolescents, prior to the initiation of sexual activity.
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Affiliation(s)
- Christiaan H Righolt
- Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Songul Bozat-Emre
- Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Epidemiology and Surveillance, Manitoba Health, Seniors and Active Living, Government of Manitoba, Winnipeg, MB, Canada
| | - Salaheddin M Mahmud
- Vaccine and Drug Evaluation Centre, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Ginindza TG, Almonte M, Dlamini X, Sartorius B. Distribution of cervical abnormalities detected by visual inspection with acetic acid in Swaziland, 2011-2014: A retrospective study. Afr J Prim Health Care Fam Med 2018; 10:e1-e7. [PMID: 30456977 PMCID: PMC6244366 DOI: 10.4102/phcfm.v10i1.1773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/12/2018] [Accepted: 08/15/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Cervical cancer is the fourth most common cancer worldwide among women, with the number of new cases increasing from 493 243 in 2002 to 527 000 in 2012. These numbers are likely to be underestimated because given the lack of registration resources, cervical cancer deaths are usually under-reported in low-income countries. AIM To describe the distribution of and trends in visual inspection with acetic acid (VIA) to detected cervical abnormalities in Swaziland by reviewing records of VIA examinations performed at two main hospitals in Swaziland between 2011 and 2014. SETTING Mbabane Government Hospital and Realign Fitkin Memorial (RFM). METHODS Records of cervical screening using VIA at the Mbabane government hospital and RFM hospital between 2011 and 2014 were retrieved. Positivity rates (PRs) of VIA with 95% confidence intervals (95% CI) were calculated and used as proxies of cervical abnormalities. Odds ratios of the association between VIA-detected cervical abnormalities and human immunodeficiency virus (HIV) status were estimated using logistic regressions. RESULTS VIA was positive in 1828 of 12 151 VIA records used for analysis (15%, 95% CI: 14.4-15.7). VIA was positive in 9% (36 of 403) women under the age of 20, in 15.5% (1714 of 11 046) of women aged 20-49 years and in 11.1% (78 of 624) of women aged 50-64 years. A decreasing trend of VIA positivity was observed over time at both screening centres (p for trend < 0.001). Of 2697 records with Papanicolaou results, 20% (67 of 331) VIA-positives and only 5% (114 of 2366) VIA negatives had high-grade squamous intraepithelial lesion. Among 4578 women with reported HIV status, 1702 were HIV-positive (37.2%, 95% CI: 35.8-38.6). The prevalence of HIV in VIA-positive women was 62.5% (95% CI: 58.7-66.2), almost double that among VIA-negative women (33.0%, 95% CI: 31.6-34.5) and that among all women screened (p < 0.001). HIV-positive women were 3.4 times more likely to have cervical abnormalities on VIA than HIV-negative women (OR: 3.4, 95% CI: 2.8-4.0, p < 0.01). CONCLUSION The high VIA PRs observed over four years in this study may reflect the prevalence of cervical abnormalities, in particular, in HIV-positive women. VIA is not a robust screening test, but it can play a major role in strengthening and expanding cervical cancer screening prevention programmes in resource-limited countries.
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Affiliation(s)
- Themba G Ginindza
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal.
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McKenna M, McMenamin M, McDowell A. HPV16 and HPV18 genotyping triage in young women with borderline cytology or mild dyskaryosis: effect of age on genotype-specific risk of high-grade CIN. Cytopathology 2016; 27:261-8. [PMID: 26873051 DOI: 10.1111/cyt.12316] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Human papillomavirus (HPV) triage of borderline cytology or mild dyskaryosis is limited by the higher prevalence of HPV in women with these findings relative to those with high-grade cervical intraepithelial neoplasia (≥CIN2). This is particularly relevant in young women in whom HPV prevalence is discernible. In a previous analysis of HPV triage and colposcopy outcomes in Northern Ireland, we revealed a substantial amount of prevalent high-grade disease in women below 30 years of age. We explored the role of genotyping for HPV16/HPV18 in this population by assessing the risk of high-grade lesions associated with these genotypes and the effect of age on type-specific risk. METHODS Of the 866 women eligible for HPV triage, those who tested positive for HPV were referred to colposcopy. The relative risk of ≥CIN2 for HPV16, HPV18 and non-HPV16/18 high-risk genotype positivity was determined for cobas(®) HPV Test-positive results. RESULTS The relative risk of high-grade CIN was significantly greater in women infected with HPV16 and/or HPV18 compared with non-HPV16/18 infections, regardless of age (2.23 and 0.45, respectively). In women under 30 years of age, HPV16-associated risk of ≥CIN2 was significantly greater than that of HPV18 and the non-HPV16/18 genotypes (1.74 versus 1.03 and 0.58, respectively). In women aged ≥30 years, HPV18 infection presented the greatest risk of ≥CIN2 (3.03). The relative risk of ≥CIN2 associated with non-HPV16/18 genotypes was lower (range, 0.32-0.58) for both age groups. CONCLUSION This analysis demonstrates the value of genotyping for HPV16/HPV18 and age stratification to improve the specificity of HPV triage and to tailor management relative to the risk of high-grade CIN and cancer.
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Affiliation(s)
- M McKenna
- Cytopathology Department, Altnagelvin Hospital, Londonderry, UK
| | - M McMenamin
- Cytopathology Department, Altnagelvin Hospital, Londonderry, UK
| | - A McDowell
- Northern Ireland Centre for Stratified Medicine, Ulster University, Londonderry, UK
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Meloni A, Pilia R, Campagna M, Usai A, Masia G, Caredda V, Coppola RC. Prevalence and molecular epidemiology of human papillomavirus infection in italian women with cervical cytological abnormalities. J Public Health Res 2014; 3:157. [PMID: 25170506 PMCID: PMC4140382 DOI: 10.4081/jphr.2014.157] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/24/2013] [Accepted: 10/02/2013] [Indexed: 01/01/2023] Open
Abstract
Background Human papillomavirus (HPV) infection is the most common sexually transmitted infection and high-risk HPV types are a necessary cause for the development of cervical cancer. The present study investigated the HPV-type specific prevalence in 650 women, aged 15-76 years, with cytological abnormalities and the association between HPV infection and cervical disease in a subset of 160 women for whom cytological results for Pap-Test were available, during the period 2008-2011 in Cagliari (Southern Italy). Design and Methods HPV-DNA extraction was performed by lysis and digestion with proteinase K and it was typed by using the INNOLiPA HPV Genotyping Assay. Results Overall the HPV prevalence was 52.6%; high-risk genotypes were found in 68.9% of women and multiple-type infection in 36.1% of HPV-positive women. The commonest types were HPV-52 (23.4%), HPV-53 (15.7%), HPV-16 (15.4%) and HPV-6 (12.4%). Among the women with cytological diagnosis, any-type of HPV DNA was found in 49.4% of the samples and out of these 93.7% were high-risk genotypes. Genotype HPV 53 was the commonest type among women affected by ASCUS lesions (21.4%), genotype 52 in positive L-SIL cases (22.5%), genotype 16 H-SIL (27.3%). Conclusions This study confirmed the high prevalence of HPV infection and high-risk genotypes among women with cervical abnormalities while, unlike previously published data, genotype HPV-52 was the most common type in our series. These data may contribute to increase the knowledge of HPV epidemiology and designing adequate vaccination strategies. Significance for public health Human papillomavirus (HPV) is the most common sexually-transmitted agent, which can cause cervical lesions and cancer in females. Efforts to reduce the burden of cervical cancer with cytology screening in the last years have had limited success. HPV infection and disease imposes a substantial burden of direct costs on the Italian National Health Service that have never been fully quantified. Monitoring HPV prevalence could represent a tool to follow the evolution of the infection in the vaccination and post-vaccination era, to understand the impact of HPV types in cervical diseases in Italy. Our survey shows an high frequency of infections sustained by HPV 52. Given the recent implementation of a widespread immunization program with vaccines not containing HPV 52, it has been relevant to prove the high prevalence of this HPV genotype from the beginning of the vaccination campaign, to avoid ascribing to the vaccination program a possible selection effect and the importance of non-vaccine HPV types in the burden of cervical disease, in order to assess the opportunity to realize new vaccine including other types.
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Affiliation(s)
- Angelo Meloni
- Section of Hygiene, Department of Public Health, Molecular and Clinical Medicine, Cagliari University , Italy
| | - Roberta Pilia
- Section of Hygiene, Department of Public Health, Molecular and Clinical Medicine, Cagliari University , Italy
| | - Marcello Campagna
- Section of Hygiene, Department of Public Health, Molecular and Clinical Medicine, Cagliari University , Italy
| | - Antonella Usai
- Section of Hygiene, Department of Public Health, Molecular and Clinical Medicine, Cagliari University , Italy
| | - Giuseppina Masia
- Section of Hygiene, Department of Public Health, Molecular and Clinical Medicine, Cagliari University , Italy
| | - Valeria Caredda
- Centre for Women Health, Local Health District of Cagliari , Italy
| | - Rosa Cristina Coppola
- Section of Hygiene, Department of Public Health, Molecular and Clinical Medicine, Cagliari University , Italy
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